GAP Exception Authorization Form

If you're a medical practice or doctor in need of a GAP Authorization processed fast and at a low price then all you need to do is fill this form out below and we will contact you within 24 hours to process.

⚠️ You do not need to be a client to use this service.
Please just fill out the form below:

Patient Information
Patient Name
Date Of Birth
MM slash DD slash YYYY
ID
Max. file size: 1 GB.
Insurance Info
Required Details
ICD 10 Codes
Procedure Codes
Location Of The Procedure
Office Name
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
NPI
Tax ID
Facility Information (Hospital/Surgery Center)
Facility Name
NPI Or Tax ID
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type Of Admission
- Inpatient
- Outpatient
Location Type
- Hospital
- Surgery Center
- Office
Continuity Of Care
- Yes
- No
Uploads For Clinicals And Notes
Max. file size: 1 GB.
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